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Universal Opt-in Form for PBOR

Universal Opt-in For Student Services PK-12

Consent for Student Support Services

SB 49 requires parental consent for the delivery of mental health support services and interventions as provided by school counselors, school psychologists, school social workers, and school nurses. These staff members strive to meet the needs of all students by visiting classrooms, working with small groups, and meeting with students to discuss age-appropriate topics such as getting along with others, staying safe, coping skills, and learning how to be a successful student.

Parents can "Opt-In" to allow our staff to provide these support services to their children. Guardians will be contacted if additional resources or services may be beneficial.

Emergency Services Notice

Please note that your child may be provided emergency mental health if there is an imminent threat to the safety of your child and/or others. Such emergency services can be delivered in the absence of parent consent.

Contact for More Information

If you have questions about completing a consent form please contact your school counselor, school psychologist or school social worker.

Consent Form Content and Example

Each school will be sending their own version of this form, but the overall content will be the same. The form will ask for their email addresses, inform parents of the need for consent to deliver services, ask for verification of reviewing the item, request electronic version of a signature and ask for student name and grade level. A completed copy of the form will automatically be sent to the email address provided by the parent.

A visual example of the electronic form is listed below.

Sample Form